Provider Demographics
NPI:1598894990
Name:BEAUDOIN, ROGER (LICSW)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BEAUDOIN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 SHIRLEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:GOFFSTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03045-2344
Mailing Address - Country:US
Mailing Address - Phone:603-497-2832
Mailing Address - Fax:
Practice Address - Street 1:279 SHIRLEY HILL RD
Practice Address - Street 2:
Practice Address - City:GOFFSTOWN
Practice Address - State:NH
Practice Address - Zip Code:03045-2344
Practice Address - Country:US
Practice Address - Phone:603-497-2832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH365104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH8001933Medicaid
NH8001933Medicaid